• RADAR2
  • TTM2

ccr logo 246x225 13121Critical Care Reviews Newsletter

September 9th 2012





Welcome to the 40th Critical Care Reviews Newsletter, bringing you the best critical care research published in the past week, plus a wide range of free full text review articles and guidelines from over 300 clinical and scientific journals.

The standout research paper this week is Angus' SPECS study, investigating tight glycaemic control in paediatric cardiac critical care, the results of which call into question any ongoing use of this practice. The review articles cover a wide spectrum, both clinical and pre-clinical, and include monitoring, endocrine emergencies, TB, mechanical ventilation and nitric oxide synthase inhibition. There are two guidelines, on the management of acute transfusion reactions and cardiopulmonary exercise testing.

The topic for This Week's Papers is ARDS, starting with an excellent overview in tomorrow's Paper of the Day. It's a free and easy way to stay up-to-date with your reading.



New England Journal of Medicine:     Glycaemic Control

Angus et al performed a two-center, prospective, randomized trial in 980 children, 0 to 36 months of age, undergoing cardiac surgery with cardiopulmonary bypass, to test whether tight glycaemic control (80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) was superior to standard care. 91% of the children assigned to tight glycemic control received insulin versus 2% assigned to standard care. Intensive insulin therapy was associated with earlier (6 hours vs. 16 hours, P<0.001) and longer proportional time period (50% vs. 33%, P<0.001) with tight glycemic control, but was not associated with a significantly decreased rate of health care–associated infections (8.6 vs. 9.9 per 1000 patient-days, P=0.67) or secondary outcomes. Only 3% of the patients assigned to tight glycemic control had severe hypoglycemia (blood glucose <40 mg per deciliter [2.2 mmol per liter]).

Full Text:  Angus. Tight Glycemic Control versus Standard Care after Pediatric Cardiac Surgery (SPECS Study). N Eng J Med 2012; epublished September 7th

Associated Editorial: Kavanagh. Glucose in the ICU — Evidence, Guidelines, and Outcomes. N Eng J Med 2012; epublished September 7th


Stroke:     Intensive Insulin Therapy

Rosso et al performed a randomized controlled trial in 180 patients with MRI-proven ischemic stroke and with National Institutes of Health Stroke Scale scores of 5 to 25 to assess whether intensive insulin therapy, compared with standard subcutaneous insulin, reduced infarct size  Although glycaemic control was tighter in the IIT group {mean capillary glucose test < 7 mmol/L in the first 24 hours (95.4% [83 of 87] versus 67.4% [60 of 89]; P<0.0001)}, the infarct growth was lower in the subcutaneous insulin group (median, 10.8 cm3; 95% CI, 6.5–22.4 versus 27.9 cm3; 14.6 – 40.7; P<0.04). The 3-month functional outcome (45.6% [41 of 90] versus 45.6% [41 of 90]), death (15.6% [14 of 90] versus 10% [9 of 90]), and serious adverse events (38.9% [35 of 90] versus 35.6% [32 of 90]) were similar in the subcutaneous insulin and IIT group.

Full Text: Rosso. Intensive Versus Subcutaneous Insulin in Patients With Hyperacute Stroke: Results From the Randomized INSULINFARCT Trial. Stroke 2012;43:2343-2349


PLoS ONE:     Renal Replacement Therapy

Shiao et al performed a multicenter retrospective observational study in 648 patients (418 men, mean age 63.0±15.9 years) to evaluate whether the timing of renal replacement therapy initiation affects the in-hospital mortality of patients with postoperative AKI. The in-hospital mortality rate was 58.5%, with both early initiation of RRT (within 1 of ICU admission) and late initiation of RRT (RRT initiation after 4 days of ICU admission) associated with increased mortality. The first peak of the U-curve represented the combined effect of poor clinical conditions (higher APACHE II scores and IE, but lower MAP) and the ischaemia/reperfusion injuries related to ECMO; older age, sepsis with subsequent complications, and later initiation of RRT were responsible for the second peak in the curve. Numerous variables were independent predictors of in-hospital mortality, including initiation of RRT within 1 day of ICU admission, age, diabetes, cirrhosis, extracorporeal membrane oxygenation support, initial neurological dysfunction, pre-RRT mean arterial pressure, inotropic equivalent, APACHE II scores, and sepsis. 

Full TextShiao. U-Curve Association between Timing of Renal Replacement Therapy Initiation and In-Hospital Mortality in Postoperative Acute Kidney Injury. PLoS ONE 2012;7(8):e42952


Acta Anaesthesiologica Scandinavica:     Perioperative Goal Directed Therapy

Bisgaard et al performed a randomized controlled trial in 70 subjects undergoing abdominal surgery to investigate the efficacy of GDT (stroke volume optimised by 250 ml colloid boluses intraoperatively and for the first 6 h post-operatively with the aim of an oxygen delivery of 600 ml/min/m2 post-operatively) versus standard care. Although both stroke volume index and oxygen delivery index  (27/32 v 18/32; P  = 0.01) were higher post-operatively in the intervention group, neither complications nor or length of ICU stay differed between groups.

Abstract:  Bisgaard. Optimising stroke volume and oxygen delivery in abdominal aortic surgery: a randomised controlled trial. Acta Anaesthesiologica Scandinavica 2012, epublished ahead of print.


PLos One:     Fluid Resuscitation in Paediatric Sepsis

Ford and colleagues undertook a systematic review and meta-analysis to assess the evidence base for fluid resuscitation in the treatment of children with shock due to sepsis or severe infection. 13 studies met inclusion criteria, although the analysis was dominated by the recent large FEAST study. No bolus has significantly better mortality outcomes at 48 hours for children with general septic shock (RR 0.69; 95%CI 0.54–0.89), and children with malaria (RR 0.64; 95%CI 0.45–0.91) when compared to giving any bolus. Colloid and crystalloid boluses were found to have similar effects on mortality across all sub-groups (general septic shock, malaria, Dengue fever, and severe malnutrition).

Full Text:  Ford. Mortality after Fluid Bolus in Children with Shock Due to Sepsis or Severe Infection: A Systematic Review and Meta-Analysis. PLoS ONE 2012; 7(8): e43953.


Trials:     New ARDS Study Protocol Announcement

The Alveolar Recruitment for ARDS Trial (ART) will be a pragmatic, multicenter, randomized (concealed) controlled trial, which aims to determine if maximum stepwise alveolar recruitment, achieving 45 cmH2O and peak pressure of 60 cmH2O, associated with with optimal PEEP titrated according to the static compliance, is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy - tidal volume 4-6 mL/kg of predicted body weight with plateau pressure ≤ 30cmH2O). The primary outcome is 28 day survival with a planned recruitment  until 520 events (deaths within 28 days).

Full Text: Cavalcanti. Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial. Trials. 2012 Aug 28;13(1):153



British Journal of Haematology:     Acute Transfusion Reactions

Full Text:  Tinegate. Guideline on the investigation and management of acute transfusion reactions Prepared by the BCSH Blood Transfusion Task Force. Br J Haematol.2012, epublished August 29th 2012


Circulation:     Cardiopulmonary Exercise Testing

Full Text:  Fletcher. Clinical Recommendations for Cardiopulmonary Exercise Testing Data Assessment in Specific Patient Populations Circulation 2012; epublished September 5th 2012 


Review - Clinical

Journal of Intensive Care Medicine:     Mechanical Ventilation


Revista da Associação Médica Brasileira:     Sepsis Diagnosis


Critical Care Research & Practice:     Monitoring


Liver International:     TIPPS


New England Journal of Medicine:     Tuberculosis


Respirology:     Tuberculosis


Cleveland Clinic Journal of Medicine:     Aldosterone Antagonists


Cleveland Clinic Journal of Medicine:     Immune Thrombocytopaenia


Neurology India:     Stroke


Indian Journal of Endocrinology & Metabolism:     Endocrine Emergencies


Indian Journal of Endocrinology & Metabolism:     Obesity


Nigerian Journal of Clinical Practice:     Phaechromocytoma


Pulmonary Medicine:     Pulmonary Complications


Review - Basic Science

Mediators of Inflammation:     Nitric Oxide Synthase Inhibitors


Frontiers in Immunology


Perspectives in Clinical Research:     Statistics



I hope you find these links and brief summaries useful.

Until next week